Citation Nr: 1318606 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 09-42 293A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for bilateral lower extremity edema, to include as secondary to service-connected kidney disease, hypertension, and heart muscle hypertrophy. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. T. Sprague, Counsel INTRODUCTION The Veteran had active service in the United States Marine Corps from October 1977 to October 1980. This matter comes before the Board of Veterans' Appeals (Board) from a November 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The appeal arises from the RO in Roanoke, Virginia. The Veteran requested a hearing before a Veterans Law Judge in order to present testimony for his appeal; however, he failed to report at the scheduled time and did not present good cause for his absence. Accordingly, his request is deemed withdrawn. The Veteran's entire claims file, to include the portion contained in the electronic "Virtual VA" system, was reviewed. FINDING OF FACT The Veteran experiences bilateral lower extremity edema; his service-connected kidney disease is totally disabling, and as such, fits the description of one of the "systemic diseases" cited by competent, credible, and uncontroverted medical literature as being one of the "most common" contributors to edema. CONCLUSION OF LAW Entitlement to service connection for bilateral lower extremity edema is warranted. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Applicable law provides that service connection will be granted if it is shown that the Veteran experiences a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service alone is not enough; there must be current disability resulting from that injury. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998) (citing Cuevas v. Principi, 3 Vet. App. 542, 548 (1992)). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in- service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Additionally, service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Certain chronic conditions, if manifest to a compensable degree within the first post-service year, will be presumed to have been incurred in active service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309 (2012). Additionally, evidence of continuity of symptomatology, irrespective of an established nexus to service, will be sufficient to substantiate a claim for service connection for "chronic diseases" listed in 38 C.F.R. § 3.309. See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As, however, the Veteran's claimed bilateral lower extremity edema does not fall into the regulatorily-defined category of a "chronic disease" for purposes of service connection, the continuity of symptomatology from service to present, without an established accompanying nexus between a current disability and service (or, in this case, to a service-connected disease), would not, in itself, be sufficient to substantiate the claim. Id. The Veteran in this case is in receipt of service-connected compensation benefits for kidney disease, hypertension, and heart muscle hypertrophy. Recently, his kidney disease was evaluated as severe enough to warrant a total rating, and the Veteran is also in receipt of special monthly compensation as a result of this disability as due to him being housebound. In essence, the Veteran contends that he experiences bilateral edema in his lower extremities, and that this condition has been caused or aggravated beyond the natural progression of the disease process by, in whole or in part, the service-connected kidney, vascular, and/or heart disabilities. He does not maintain that lower extremity edema had causal origins in service. For reasons discussed below, the Board agrees with the Veteran's assertions. There is only one opinion of record that purports to address etiology, and this was associated with a VA examination offered in October 2008. At that time, bilateral lower extremity edema was diagnosed, and the examiner noted that "diabetes also causes vascular problems that might limit the return of the blood flow to the heart therefore causing edema to the lower extremities." With respect to the interplay of the vascular, kidney, and heart conditions, the examiner stated that any opinion he could offer would be "pure speculation." There is no associated rationale as to why this is the case, and the examiner did not describe if the reasons for speculation result from a limitation in the medical community or, alternatively, result from a lack of personal knowledge. It would seem as if the opinion potentially links nonservice-connected diabetes with the edema; however, even in describing this, the examiner's usage of terms such as "might limit" implies that there are, potentially, several other factors which could also contribute to the Veteran's edema. Pertinently, the examiner did not specifically rule-out a causal relationship to service-connected conditions; rather, he stated that he could not personally address the contention without speculating. The 2008 opinion is equivocal and not particularly helpful in resolving the appeal on its own. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran, in response to this, submitted several supportive internet articles which appear to be from credible medical sources. One of these articles, from a site in which physicians are credited as authors, states that "edema is caused by systemic diseases...or by local conditions involving just the affected extremities." It went on to state that "the most common systemic diseases associated with edema involve the heart, liver, and kidneys." It was explained that "in these diseases, edema occurs primarily because of the body's retention of too much salt...[which] causes the body to retain water." Another physician-authored internet article, done for the American Society of Clinical Oncology (but not, however, limited to cancer patients), also noted that problems in kidney and heart functioning, as well as medications for blood pressure management, may be responsible for edema. As noted, the Veteran's kidney disease is severely disabling, and he is also in receipt of a separate 20 percent evaluation and a 30 percent evaluation for hypertension and hypertrophy of the heart muscles, respectively. The internet articles are not specific to the Veteran's condition; however, they are consistent in establishing that kidney and heart "systemic diseases" are " most common[ly]" associated with the development of edema. As the Veteran's kidney disease, specifically, is very severe, it is not unreasonable to conclude that such a condition, with or without the interplay of other factors, would fit into the noted "most common" cause for edema as established by the submitted medical literature. There is nothing of record submitted to contradict this, and the afforded medical opinion of 2008, in offering a speculative medical opinion, made no reference to whether the Veteran's kidney, heart, and vascular conditions would fall outside of what are "most common" causes for edema in general. The Board is prohibited by law from substituting its own medical judgment for that of a medical professional. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). In this case, however, there is no negative medical opinion of record (only a speculative one), and the submitted medical literature is credible and supportive of the Veteran's contentions. The Board can draw the conclusion, based on this medical evidence, that in general, kidney and heart systemic disease (and, potentially, the use of anti-hypertensives), play a causal role in the development of edema. As the 2008 VA physician seemed to note that there are numerous causes for edema (which, per his notation, would also seem to include nonservice-connected diabetes), the medical journal entries would be consistent with his examination report. Furthermore, as the 2008 VA examiner could not offer an opinion without speculation as to the contributory role of kidney, heart, and vascular disabilities and the onset of edema, the Board can also conclude that there was nothing so specific to the Veteran's condition as to merit an exception in his case as to the general causes of edema as listed in the submitted medical literature. Thus, the Board is satisfied that it is relying on expert written medical evidence, and not its own medical judgment, when utilizing the submitted medical literature, in concert with the 2008 opinion, in coming to a conclusion. The Board is not comfortable, however, without further medical evidence, to offer an analysis as to if the heart and vascular dysfunction are, in themselves, disabling enough so as to arise to the level of the "most common systemic disease[s] associated with edema" as described in the submitted medical evidence. The assigned ratings for those conditions, and the evidence associated with the claims file, do not make it abundantly clear as to if the Veteran's heart and vascular disease are, in themselves, enough to be so extensive as to be systemic diseases contributing to the edema. With the total rating assigned for the kidney disease, however, the Board notes that there is severe disease present for that anatomical system, and the Veteran is deemed totally disabled by VA for that condition alone (based on this fact, further development of this case is simply not warranted - the Veteran is already at a total rating and receives special monthly compensation based on housebound criteria - making a remand of this case highly unproductive). Indeed, in an opinion offered with an unrelated claim, a July 2010 VA examination report expressed the fact that the Veteran's kidney disease had worsened to the point that dialysis was needed. Thus, the Board can conclude that there is most certainly disablement of the kidney present that cannot be evaluated at a higher level, and that accordingly, it is reasonable to assume that such a disorder would fit into what the submitted medical literature describes as being a "systemic disease" that is "most common[ly] associated with edema." As such, the evidence indicates that, at the very least, it is at least as likely as not that the Veteran's service-connected kidney disease played a causal role in the development of bilateral lower extremity edema (or, at the very least, aggravated the condition). Accordingly, irrespective of other potential contributing factors (both service-connected and nonservice-connected), the Board is able to grant the claim based on this evidence. ORDER Entitlement to service connection for bilateral lower extremity edema is granted. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs